LiveCareer-Resume

claims processor ii resume example with 20+ years of experience

Jessica
Claire
resumesample@example.com
(555) 432-1000,
, , 100 Montgomery St. 10th Floor
:
Summary

Detailed Claims Processor with 38 years of experience investigating claim information for correctness. Trustworthy teammate with benefit knowledge and rapport-building skills. Noted for thoroughness and ethical customer service. Seasoned Claims Processor evaluating online entry, error correction and quality control review for final adjudication of claims. Strong business and financial acumen with proven success to maintain efficient operations. Extensive knowledge of billing, collections and fiduciary management. Seasoned medical Insurance Specialist with excellent planning and problem solving abilities. Offering 38 years of experience and a willingness to take on any challenge. Organized, driven and adaptable professional with successful history managing high caseloads in fast-paced environments. Hardworking employee with customer service, multitasking and time management abilities. Devoted to giving every customer a positive and memorable experience.

Skills
  • Claims Review
  • Payments Posting
  • Transactions Reconciliation
  • Service Referrals
  • Insurance Claim Forms Review
  • New Policies Processing
  • Eligibility Determination
  • Verbal and Written Communication
  • Customer Service
  • Problem-Solving
  • Teamwork and Collaboration
  • Claim Amount Calculations
Education and Training
Westminster High School Westminster, CA Expected in 06/1978 High School Diploma : - GPA :
Experience
Bluecross Blueshield Of South Carolina - Claims Processor II
Wyoming, WY, 09/2014 - Current
  • Verified claim data correctness in preparation for processing.
  • Processed claims according to established quality and production standards and made corrections and adjustments to solve problems.
  • Reviewed history records to determine benefit eligibility for services.
  • Researched medical claims for validity to resolve discrepancies.
  • Analyzed contracts and claim systems to apply appropriate benefit amounts.
UnitedHealthcare - Lead-claims Trainer
City, STATE, 03/1998 - 02/2012
  • Verified claim data correctness in preparation for processing.
  • Processed claims according to established quality and production standards and made corrections and adjustments to solve problems.
  • Reviewed history records to determine benefit eligibility for services.
  • Addressed customer inquiries to provide information and explanations on coverage and terms, expediting claims.
  • Researched medical claims for validity to resolve discrepancies.
  • Coordinated benefits with medical insurance plans and Medicare providers.
  • Analyzed contracts and claim systems to apply appropriate benefit amounts.
  • Conducted and documented comprehensive investigations to negotiate settlements or deny claims.
  • Built rapport and trust with injured insureds through effective customer service techniques which involved fair and prompt processing of claims.
  • Identified client service improvement opportunities in collaboration with team leads and managers to resolve problems.
  • Assisted claimants, providers and clients with problems or questions regarding claims.
  • Processed claims for payment or forwarded to appropriate personnel for further investigation
  • Assisted new policyholders with processing claims.
  • Explained goals and expectations required of trainees.
  • Monitored, evaluated and recorded training activities or program effectiveness.
  • Suggested and offered specific training programs to help workers maintain or improve job skills.
  • Participated and attended meetings or seminars to obtain information for use in training programs or to inform management of training program status.
  • Obtained and organized manuals, guides and visual materials for development and training purposes.
  • Evaluated training materials prepared by instructors and offered actionable suggestions for improvement.
Aetna - Lead Trainer Claims
City, STATE, 07/1985 - 11/1997
  • Verified claim data correctness in preparation for processing.
  • Processed claims according to established quality and production standards and made corrections and adjustments to solve problems.
  • Reviewed history records to determine benefit eligibility for services.
  • Addressed customer inquiries to provide information and explanations on coverage and terms, expediting claims.
  • Researched medical claims for validity to resolve discrepancies.
  • Coordinated benefits with medical insurance plans and Medicare providers.
  • Analyzed contracts and claim systems to apply appropriate benefit amounts.
  • Assisted claimants, providers and clients with problems or questions regarding claims.
  • Examined claims, records and procedures to grant approval of coverage.
  • Processed claims for payment or forwarded to appropriate personnel for further investigation
  • Modified and updated existing policies and claims to reflect change in beneficiary, amount of coverage or type of insurance.
  • Handled modification and updating of policies.
  • Checked documentation for appropriate coding, catching errors and making revisions.
  • Used insurance rate standards to calculate premiums, refunds, commissions and adjustments.

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Resume Overview

School Attended

  • Westminster High School

Job Titles Held:

  • Claims Processor II
  • Lead-claims Trainer
  • Lead Trainer Claims

Degrees

  • High School Diploma

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